State/National Statistics:Basic Epidemiology of

Skin Cancer

Presented by: Chris Johnson, MPHEpidemiologist, Cancer Data Registry of Idaho

4th Annual Conference on Advancing Cancer CareSkin Cancer and Management of Treatment-Related Fatigue

April 22-23, 2004McCleary Center

Saint Alphonsus Regional Medical Center

Outline

• Skin• Skin Cancer

– SCC and BCC– Melanoma

• Melanoma– Risk Factors– Incidence– Stage– Survival– Mortality– Lifetime Risks– Prevention

The Skin

• The skin is the body’s largest organ. It protects against heat, sunlight, injury, and infection. It helps regulate body temperature, stores water and fat, and produces vitamin D.

• The skin has two main layers: the outer epidermis and the inner dermis.

Skin Cancer

• Cancer may develop in any of the cell types:– Squamous Cell Carcinoma (SCC)– Basal Cell Carcinoma (BCC)– Melanoma

• Skin cancer is the most common form of cancer in the United States.

Squamous and Basal Cell Carcinomas

• The American Cancer Society estimates that approximately 1.3 million new cases of basal cell and squamous cell carcinomas will be detected this year. This is roughly equivalent to the total of all other cancer sites.

• Death rates from basal cell and squamous cell carcinomas are low.– When detected early, approximately 95% of these carcinomas can

be cured. – However, these cancers can cause considerable damage and

disfigurement if they are untreated.• Basal cell and squamous cell carcinomas are more than 10 times as

common as melanoma but account for less morbidity and mortality. – SCC may account for 20% of all deaths from skin cancer.

• SCC and BCC are not reportable to CDRI unless regional or distant stage or on a mucous membrane. – There were 11 reportable SCC and BCC skin cases in 2002.

• We do not know how many total cases of SCC and BCC there are per year in Idaho, but estimate it to be over 5,000.

Melanoma of the Skin• Melanoma is one of the most common cancers and the

most serious type of cancer of the skin.• The American Cancer Society estimates that about

54,200 new cases of malignant melanoma will be diagnosed this year, and 7,600 will die from the disease in the US.

• In some parts of the world, especially among Western countries, melanoma incidence is on the rise.– In the United States, melanoma incidence has more

than doubled in the past 30 years.• All in situ and invasive melanoma cases are reportable to

CDRI.

Risk Factors

• Light skin color, hair color, or eye color. • Family history of skin cancer. • Personal history of skin cancer. • Chronic exposure to the sun. • History of sunburns early in life. • Certain types of moles, or a large number of

moles. • Freckles, which indicate sun sensitivity and sun

damage.

Ultraviolet Radiation

EARTH SURFACE

UV Radiation Wavelengths• Ultraviolet radiation (or UV radiation)— Electromagnetic radiation

with wavelengths between 100 and 400 nanometers. These rays are emitted from the sun and are not visible. They inflict increasingly more damage upon a recipient as the wavelength decreases. Based on its effects, UV radiation is subdivided into three wavelength ranges named UV-A, UV-B and UV-C:– UV-A covers the wavelength range 320-400 nm. UV-A is not absorbed

by the ozone layer and is the least harmful UV radiation (tanning beds).

– UV-B covers the wavelength range 280-320 nm. UV-B is more energetic than UV-A, and is partially absorbed by the ozone layer. UV-B rays that are not filtered out cause sunburn and other harmful effects to humans.

– UV-C covers the wavelength range 100-280 nm. UV-C is the most dangerous form of UV radiation, but is completely absorbed by the ozone layer. Artificial UV-C (for example emitted by electric discharges) is a threat for certain occupational group, like welders.

UV Exposure• More than 90% of skin cancers in the US are attributed

to UV-B exposure.– Other causes of skin cancer include arsenic, other chemical

exposures.• Human exposure to UV-B depends upon an individual's

– location (latitude and altitude)– the duration and timing of outdoor activities (time of

day, season of the year = angle of the sun)– and precautionary behavior (use of sunscreen,

sunglasses, or protective clothing).

UV Exposure

Ozone Layer Depletion

• Is ozone loss to blame for the melanoma upsurge in the US and Europe?– Unlikely:

• UV-B has not yet increased much in the US and Europe• Melanoma takes 10-20 years to develop. There hasn't been

enough time for ozone depletion to play a significant role.

• Current and future increases in UV radiation exposure due to ozone depletion will exacerbate the trend toward higher incidence of melanoma.

UV-B Exposure - Sunburn

– 32% of U.S. adults report having had a sunburn in the past year

– Parents or caregivers reported that 72% of adolescents aged 11--18 years have had at least one sunburn, and 43% of white children aged <11 years experienced a sunburn in the past year.

SunburnPercentage of Adults who had a Sunburn in Last 12 Months

2003 Idaho BRFSS

0

10

20

30

40

50

60

70

80

90

100

Statewide HD 1 HD 2 HD 3 HD 4 HD 5 HD 6 HD 7

Per

cent

Percent

(Preliminary Data)

Sunburn

Percentage of Adults who had a Sunburn in Last 12 Months2003 Idaho BRFSS

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

18-24 25-34 35-44 45-54 55-64 65+

Per

cen

t

Percent

(Preliminary Data)

Synopsis of Melanoma in Idaho

• In 2002, there were 263 invasive cases of melanoma and 41 melanoma deaths among Idaho residents.

• Melanoma is the 5th most common cancer in Idaho in terms of incidence and 15th most common cause of cancer death.

Melanoma Incidence 2002

Geography Rate Count PopulationHealth District 1 19.3 40 184,327Health District 2 12.2 13 99,799Health District 3 17.4 34 205,719Health District 4 21.5 68 363,761Health District 5 14.7 24 165,289Health District 6 19.0 27 158,040Health District 7 26.3 38 164,196State of Idaho 20.5 263 1,341,131SEER Whites 2000 20.9 4,366 20,536,218SEER All Races 2000 17.7 4,591 26,723,142Rates are per 100,000 and age-adjusted to the 2000 U.S. (18 age groups) standard.

13

13.6

16.0

16.4

17.0

22.9

26.9

54.0

66.3

166.6

15.9

12.8

15.2

16.9

37.8

23.4

22.5

62.5

79.8

176.9

0 20 40 60 80 100 120 140 160 180 200

Oral Cavity and Pharynx

Pancreas

Leukemia

Kidney and Renal Pelvis

Bladder

Non-Hodgkin Lymphoma

Melanoma of the Skin

Colorectal

Lung and Bronchus

Prostate

Age-Adjusted Rate per 100,000

SEER 2000

Idaho 2002

Top 10 Cancer Incidence - Males

10.5

11.6

12.0

13.8

14.7

17.5

20.3

33.8

43.8

131.2

8.3

16.3

9.4

10.8

14.4

15.4

24.4

45.9

49.8

135.1

0 20 40 60 80 100 120 140 160 180 200

Kidney and Renal Pelvis

Ovary

Leukemia

Thyroid

Melanoma of the Skin

Non-Hodgkin Lymphoma

Endometrium

Colorectal

Lung and Bronchus

Breast

Age-Adjusted Rate per 100,000

SEER 2000

Idaho 2002

Top 10 Cancer Incidence -Females

IncidenceMelanoma of the Skin Incidence, 1990-2001

Males

25.8

21.9

3.9

6.8

1.4

1.8

2.2

9.4

5.1

0.0 5.0 10.0 15.0 20.0 25.0 30.0

SEER

Idaho

SEER

Idaho

SEER

Idaho

SEER

Idaho

SEER

Idaho

Non

-H

ispa

nic

Whi

teH

ispa

nic

Bla

ck

Asi

an o

rP

acifi

cIs

land

er

Am

eric

anIn

dian

/A

lask

aN

ativ

e

Age-Adjusted Rate Per 100,000

IncidenceMelanoma of the Skin Incidence, 1990-2001

Females

17.2

15.8

3.9

9.2

0.9

1.4

3.8

1.8

4.9

0.0 5.0 10.0 15.0 20.0 25.0 30.0

SEER

Idaho

SEER

Idaho

SEER

Idaho

SEER

Idaho

SEER

Idaho

Non

-H

ispa

nic

Whi

teH

ispa

nic

Bla

ck

Asi

an o

rP

acifi

cIs

land

er

Am

eric

anIn

dian

/A

lask

aN

ativ

e

Age-Adjusted Rate Per 100,000

Incidence by AgeMelanoma of the Skin Incidence, 1998-2002Age-specific Rates

0

20

40

60

80

100

120

140

00-0

4

05-0

9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85+

Age Group (in years)

Rat

e p

er 1

00,0

00 p

erso

n-y

ears

Idaho Male

SEER White Male

Idaho Female

SEER White Female

Incidence 2000 White Males

Incidence 2000 White Females

Incidence Trends

0

5

10

15

20

25

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

Year

Ag

e-A

dju

sted

Rat

es

Idaho

SEER

SEER Summary Staging 2000• Cancer staging is the process of describing the

extent of the disease or the spread of the cancer from the site of origin.– In situ – noninvasive; basement membrane of

epidermis is intact (Clark’s level I)– Localized – papillary/reticular dermis invaded (Clark’s

level II-IV)– Regional – subcutaneous tissue invaded (Clark’s

level V), satellite nodules <= 2 cm from primary tumor, regional lymph nodes involved

– Distant – extension to underlying cartilage, bone, skeletal muscle, metastasis to skin or subcutaneous tissue beyond regional lymph nodes or visceral metastasis

Incident Cases by StageMelanoma Cases by Stage

3,834 420

500 30142

16115 41

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

SEER 2000 Idaho 01-02

Per

cen

t o

f T

ota

l C

ases

Unstaged

Distant

Regional

Localized

Melanoma Trends by SEER Summary Stage

0

5

10

15

20

25

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

Age

-Adj

uste

d In

cide

nce

Rat

es

In situ Idaho

Localized Idaho

Regional Idaho

Distant Idaho

In situ SEER

Localized SEER

Regional SEER

Distant SEER

Cancer Survival

Site % Survival Site % SurvivalThyroid 96% Colon 60%Prostate 94% Kidney and Renal Pelvis 60%Testis 91% Non Hodgkins Lymphoma 57%Breast 86% Leukemia 46%Melanoma of the Skin 85% Ovary 42%Endometrium 84% Brain 29%Hodgkins Lymphoma 79% Multiple Myeloma 28%Oral Cavity and Pharynx 68% Stomach 20%Larynx 65% Lung and Bronchus 12%Cervix 65% Esophagus 10%Rectum & Rectosigmoid 63% Liver 8%Bladder 62% Pancreas 4%

5-Year Relative Cancer Survival, 1991-2000 Idaho Cases

Melanoma Survival by Stage

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

1 2 3 4 5 6 7 8 9 10

Years Survival

Per

cen

t R

elat

ive

Su

rviv

al

Localized SEER 91-2000

Localized Idaho 91-2002

Regional SEER 91-2000

Regional Idaho 91-2002

Distant SEER 91-2000

Distant Idaho 91-2002

Melanoma Mortality 2002

Geography Rate Count PopulationHealth District 1 4.2 8 184,327Health District 2 3.6 4 99,799Health District 3 3.0 3 94,801Health District 4 4.1 11 363,761Health District 5 1.9 3 165,289Health District 6 5.0 7 158,040Health District 7 1.3 2 164,196State of Idaho 3.3 41 1,341,131US Whites 2000 3.0 7,245 230,019,590US All Races 2000 2.7 7,420 281,421,906Rates are per 100,000 and age-adjusted to the 2000 U.S. (18 age groups) standard.

Leading Causes of Mortality and Melanoma - Males

3.8

17.7

27.9

30.6

56.1

76.9

62.8

49.4

106.6

249.8

321.6

1,058.3

5.6

27.9

28.1

30.5

57.9

58.1

60.2

62.1

113.5

207.6

252.6

929.4

0.0 200.0 400.0 600.0 800.0 1,000.0 1,200.0

Melanoma of the Skin

Suicide

Diabetes Mellitus

Prostate Cancer

COPD

Lung Cancer

Cerebrovascular Diseases

Accidents and Adverse Effects

Other Cause of Death

All Malignant Cancers

Diseases of Heart

All Causes of Death

Age-Adjusted Rate per 100,000

Idaho 2002

US 2000

Leading Causes of Mortality and Melanoma - Females

1.8

22.9

26.7

19.2

22.0

41.2

37.2

58.7

87.7

167.3

209.9

728.6

1.3

23.7

25.2

28.5

31.4

33.0

43.0

58.1

97.5

148.1

162.1

677.5

0.0 200.0 400.0 600.0 800.0 1000.0 1200.0

Melanoma of the Skin

Diabetes Mellitus

Breast Cancer

Alzheimers

Accidents and Adverse Effects

Lung Cancer

COPD

Cerebrovascular Diseases

Other Cause of Death

All Malignant Cancers

Diseases of Heart

All Causes of Death

Age-Adjusted Rate per 100,000

Idaho 2002

US 2000

Mortality 1996-2000 White Males

Mortality 1996-2000 White Females

Mortality Trends

0

0.5

1

1.5

2

2.5

3

3.5

4

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

Year

Ag

e-A

dju

sted

Rat

es

Idaho

US

Risks of Developing and Dying from Melanoma

If your currentage is:

30 1 in 758 1 in 287 1 in 135 1 in 77 1 in 56 1 in 4640 1 in 456 1 in 162 1 in 84 1 in 60 1 in 4950 1 in 244 1 in 100 1 in 66 1 in 5360 1 in 159 1 in 85 1 in 6370 1 in 155 1 in 8780 1 in 130*

If your currentage is:

30 1 in 5272 1 in 1674 1 in 894 1 in 440 1 in 285 1 in 21740 1 in 2418 1 in 1062 1 in 474 1 in 297 1 in 22350 1 in 1840 1 in 573 1 in 329 1 in 23960 1 in 780 1 in 376 1 in 25870 1 in 616 1 in 32680 1 in 451*

Note: * Risks are not precise - best estimates are shown.

Then your risk of dying from melanoma by a particular age is:

By age 40 By age 50 By age 60 By age 70 By age 80 Ever

Melanoma in Males

Then your risk of developing melanoma by a particular age is:

By age 40 By age 50 By age 60 By age 70 By age 80 Ever

Risks of Developing and Dying from Melanoma

If your currentage is:

30 1 in 716 1 in 296 1 in 174 1 in 113 1 in 84 1 in 6840 1 in 501 1 in 227 1 in 133 1 in 94 1 in 7450 1 in 408 1 in 178 1 in 113 1 in 8560 1 in 303 1 in 150 1 in 10370 1 in 263 1 in 13880 1 in 219*

If your currentage is:

30 1 in 23414 1 in 7968 1 in 2551 1 in 1517 1 in 740 1 in 49740 1 in 11980 1 in 2840 1 in 1609 1 in 758 1 in 50450 1 in 3657 1 in 1826 1 in 795 1 in 51660 1 in 3498 1 in 975 1 in 57770 1 in 1206 1 in 61680 1 in 948*

Note: * Risks are not precise - best estimates are shown.

Then your risk of dying from melanoma by a particular age is:

By age 40 By age 50 By age 60 By age 70 By age 80 Ever

Melanoma in Females

Then your risk of developing melanoma by a particular age is:

By age 40 By age 50 By age 60 By age 70 By age 80 Ever